Healthcare Provider Details

I. General information

NPI: 1023329018
Provider Name (Legal Business Name): IVY BJORNSON LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 NE 47TH ST STE 101
SEATTLE WA
98105-4685
US

IV. Provider business mailing address

4111 SW MONROE ST
SEATTLE WA
98136
US

V. Phone/Fax

Practice location:
  • Phone: 206-527-0123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberMA 60141852
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: